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Cards II
Lectures 1-whatever
207
Medical
Graduate
03/01/2015

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Cards

Term
Hear a diastolic murmur, next step and why
Definition
echo is ordered b/c most diastolic murmurs are pathologic
Term
Hear a continuous murmur, next step and why
Definition
Echo is ordered, b/c most continuous murmurs are pathologic
Term
Phase most murmurs are found in
Definition
Systolic
Term
Parasternal heave
Palpable thrill
Pt leans forward, holds breath after exhalation, diastolic murmur
Pt on L side exhales --> diastolic murmur
Pt on L side--> sysotolic murmur
Definition
RVH
Aortic Stenosis
Aortic regurg--->L3rd ICS
Mitral stenosis--> L5th ICS
Mitral Regurg --> axilla
Term
When you hear a murmur tells
Where you hear a murmur tells
What you hear with a murmur tells
Definition
Systolic/diastolic
location
regurg/stenosis
Term
Murmur is loud/ changing:
tells us
what next
Definition
body is compensating, relieve the stress the body is compensating for
Term
Causes of:
An obstruction
Increaesed normal blood flow
Regurgitant flow across an incompetent valve
Abnormal shunting of blood
Definition
AS
Aortic murmur w/ high output state/anemia
Mitral valve prolapse
VSD
Term
Valve open + murmur =
During Systole valve position
During Diastole valve position
If suppposed to be open think,
If suppose to be closed think,
Definition
AS
AV closed/ SL open
AV open/ SL closed
stenosis
regurge/ prolapse
Term
Sysolic murmur by positon:
RUSB =
LUSB =
Erb's =
LLSB =
APEX =
Definition
AS
PS, PDA
HCM
TR, VSD
MR, MVP
Term
systolic Crescendo- decreschendo, increases and decreases w/
Definition
valsalva/standing, squatting
Term
Diastolic murmur location
LUSB=
Erb's=
LLSB =
Apex =
Erb's point, exhale/hold breath while leaning forward
Continuous murmur location:
LUSB =
LUSB/RUSB/back/ clavicals =
Definition
pulmonic regurg/ split S2
Aortic regurg
TS
MS
AI/AR
PDA
Venous Hum
Term
1. Machine like Benign sound, turbulent sound in 2. Jugular veins, children, over clavicals, Loud diastole
Definition
PDA Venous Hum
Term
Early to mid systolic, soft (I-II/VI), breathing variant, normal exam & w/u, no family Hx
Definition
Benign Murmur
Term
All diastolic murmurs (besides...), all pan-systolic murmurs, late systolic murmurs, LOUD murmurs, Continuous murmurs
Definition
Pathologic murmurs besides Venous Hum
Term
non-suppurative sequelae occuring 2-3 weeks post pharyngeal infection w/ GAS, 5-15 y/o, Rampant in underdeveloped countries....Philipines
Definition
ARF
Term
Previously MCC of valvular heart dz, decreased due to PCN, school aged children
Definition
ARF
Term
Scarlet fever
Definition
ARF
Term
Important ARF presentation patient Hx question
Definition
Hx of Strep throat in family
Term
morbid condition following/occuring as a consequence of another condition
Definition
sequelea
Term
Arthritis affects numerous joints- presents one joint at a time, abnormal heart beat, CP, red patches on skin, small painless lumps beneath skin, rapid involuntary extremity/facial movements
Definition
GAS Specific Sx, 5-15 y/o
Term
areas of focal necrosis surrounded by inflammatory cells, plasma cells, macrophages--form fibrous scar tissue
Definition
ARF--Aschoff bodies
Term
Major JONES criteria
Rubor, calor, dolor, <4 wk duration, migratory
New MS/AI; cardiomegaly, CHF, Aschoff bodies
Firm, painless nodules, wrist/elbows/knees/achilles tendon- erupt with murmur formation
Milk maid's sign-->explain
Patches, not painful/itchy, on trunk no migration to face, hot shower provokes
Minor JONES Cirteria
How many of each
Definition
Joints(polyarteritis), carditis, nodules(SQ), erythema marginatum, syndeham chorea
Milkmaid grip->grip increase then decrease, males, neurlogic d/o
Arthralgias, Fever, elevated ESR/CRP, heart block, Prior Hx of RF
2 Major/ 1 Major; 2 Minor
Term
1st sign of ARF
Last sign of ARF
Definition
Polyartertitis
Chorea/ SQ nodules
Term
ASO/Anti-DNase B/ ASTZ- if 1+ is (+) what's next
Definition
Apply Jones Criteria and see if strep is found
Term
1. GAS + Jones Citeria =
2. Presumptive Dx can be made with which follow circumstances
3.CXR with patients with RF
Definition
ARF
Strep + 2 major/ Strep + 1 major and 2 minor
2. Chorea is the only manifestation
Indolent carditis- pt doesn't get medical care early
Recurrent RF- considered if any RF manifestations arise
3. Cardiomegaly/Heart Failure
Term
1.Common ECG finding in carditis
2.Progression of this arrhythmia
Definition
1. Heart Block
2. 1st - 2nd(I-Wienkebach, II-Mobitz) - 3rd (KNOW THESE BLOCKS
Term
1.Tx of ARF
2.% of recurrent infections...
3.Why hospitalize
Definition
1.Acute Sx relief

Bed Rest
Sx relief until all Sx/ESR,CRP are normal
GAS eradication= ABX

GAS prophylaxis=

Hospitalization
2. 50%
3.MC age 5-15y/o, heart is affected, potentially high HB occurance-bad
Term
Tx of ARF specific Sx:
Acute Sx relief
Carditis
ABX Eradication
ABX prophylaxis
Definition
pericardial inflammation= (ASA-100mg/kg)/(Predinsone: 1-2mg/kg for 4-12wks, taper)
HB/HF= conventional Tx/valve repair
Rash=antihistamine
ABX Eradication:
Penicillin VK: Child-250mg, >12 500mg both BID
PCN all= Macrolide
(+/-) pharyngitis, household contact TC- Tx (+)
Prevention:
RF + carditis + valvular dz=10yr/40y/o
RF + carditis - valvular dz=10yr/21y/o
RF - carditis = 5 yrs/ 21y/o
Term
Most severe sequelea of ARF
Occurs.... years after the original dz
MC affected valves
Definition
Rheumatic heart dz
10-20 yrs
Mitral (MS), but also Aortic
Term
Most common cardiac valve lesion in US
In North America dz is due to
Most common valve lesion in the world
Definition
AS
degenerative calcific diseased valve wear and tear
Rheumatic valve dz, mitral valve involvement
Term
Dyspnea on exertion/ decreased exercise tolerance, exertion dizziness, exertion angina- related to valve d/o
Definition
AS
Term
Pulsus parvus et tardus, best heard in
S4 related to
Definition
AS, carotid artery
A stiff wall
Term
Cardinal Sx of advance/end stage dz and average survival after onset of AS
Definition
Angina - 5 yr
Exertional Syncope - 3yr
CHF 2 yr
Dyspnea 2 yr
A fib 6mo- precipitates overt HF and can increase mortality rates
Term
Why does AS cause:
Syncope
CHF
Definition
1. LV cannot push out enough blood to feed the brain due to vasodilation and reduced orifice opening
2.Pressure built up in LV causes LA to fill with blood resulting in an increase in lung fluid causing congestion
Term
Systolic, harsh, best heard at RUSB, radiates to carotids
selective radiation of high frequency AS to apex is known as...
Definition
1. AS
2. Galverdian phenomenon - may be confused for MR
Term
Diagnosis and Evaluation of AS
Echocardiogram if:
2 things we look at
Exercise Testing
Definition
done every 6-12 mo Vmax >=4m/s (stage C/severe)
ANY CHANGE in Sx
Jet velocity and valve area3-4cm, normal is 3.5
ASX severe AS to confirm absence of Sx
Term

AS: Tx additional informatio-

1. How beneficial is medical Tx of AS?

2.Who should be approached with extreme caution and Tx with this concomittance?

3.Which Rx should be avoided in all AS pt?

4. Definitive Tx = ?

5. Definitive Tx for young adults with congenital AS?

Definition
1.no proven delay in progression 2.extreme caution with anti-HTN, start and titrate slow with close monitoring 3.Diuretics should be avoided- could lead to further decrease in CO 4.Aortic valve replacement 5. balloon aortic valvuloplasty- effective in young adults with congenital AS
Term
MC etiology in developed countries is due to abnormalities of valve leaflets/dilation of aortic root?
Most common etiology in underdeveloped countries is rheumatic heart dz?
Definition
Aortic regurgitation
Term
1. Cause of aortic root dilation in Aortic regurgitation
Definition
Syphillis
Term
MC acute native valve medical emergency related to Aortic Insufficiency?
Definition
Endocarditis
Aortic dissection
Term
Result of:
Acute AR
Chronic AR
Definition
1. rapid decompensation-->inability to compensate increased EDP, backs up into the LA-->Lungs
2. Ventricular dilation-->CHF-->widened pulse pressure to push out extra blood
Term
"water hammer" pulse
Prolonged asymptomatic period
DOE/orthopnea, PND
Definition
1.Aortic Insufficiency
2.CHF
Term
Clinical features:
Head bobbing with systole-forceful extra stroke volume
Water-hammer -
Capillary pulsations in the nail beds-
Pistol shot sounds over radial/femoral artery -
To-and-from femoral murmur
Definition
DeMusset's sign
Corrigan's Pulse
Quincke's pulse
Traube's sign
Duroziez's sign
Term
Blowing diastolic murmur, accentuated with sitting up, leaning forward, exhaling, Erb's, Heard best RSB and apex, Austin Flint Murmur
Definition
Aortic Insufficiency
Term
Aortic Insufficiency
CXR- acute-
Chronic-
Definition
pulmonary edema
LVH, enlarged cardiac silhouette
Term
Aortic Insufficiency: Echocardiogram
Echocardiogram
Definition
Confirm the presence and severity of acute
Determine the cause of chronic AR
Determine LV function, detect LV changes: hypertrophy, dimension/volume, and systolic function
For enlarge aortic root assess regurgitation and the severity of aortic dilation
Periodic re-evaluation-severe AR
Term
Frequency of monitoring Aortic Insufficiency
Definition
3-5 yrs mild-Stage B
1-2 yrs moderate-Stage B
6-12 mo
re-evaluate mild/moderate/severe AR with new/changing Sx
Term
Aortic Regurgitation and SX
Definition
Most are not candidates, they generally not Sx at mild/moderate
Term
Dx testing for Aortic Regurgitation
Definition
Radionucleotide angiography/MRI- initial/serial-->suboptimal echo
Cardiac Cath: when noninvasive tests are inconclusive
Exercise stress testing: for chronic AR
Term
Medical Tx Aortic Regurgitation
Definition
Pharmacologic Tx- no Tx required in asymptomatic patients
Vasodilators- for severe AR, patients w/ Sx or reduced LV who are not SX candidates
Surgical Tx- Aortic valve replacement is only effective for severe AR
Term
Aortic Insufficiency Prognosis
Without SX death occurs:
Definition
Chronic progression over 10 yrs
>4 yrs after angina
>2 yrs after HF symptoms
Term
MS worsens with:
Pulmonary hypertension Passive v. Reactive
Definition
1.A-fib, tachycardia, Pregnancy (increase preload)
2. passive = pressure increase from backward flow of blood from LA
Reactive = pulmonary arterial/arteriolar vasoconstriction, PA hypertrophy
Term
Increased LA pressure --> pathophysiology end result and Sx
Why does this worsen with A fib?
Why does this worsen with tachycardia?
Why does it worsen with pregnancy?
Definition
1. back up of blood -- > transudates in the lungs --> dyspnea
2. lack of atrial kick --> less blood into LV --> decreased CO
3. Shorter emptying time--> increased volume left in atrium
4. increased volume of blood (preload) for mom and baby--> pathology of MS is the same but now increased volume leads to increased volume left in the LA
Term
Diastolic murmur, OS, best heard at the apex while in the LLDP
Severity is dependent on...
Definition
1.MS
2. duration of the murmur
Term
Orthopnea, RHF, Dysphonia
Definition
MS- Pillows needed to sleep, caused by LHF, Dilated LA impinges the recurrent larygeal nerve
Term
ECG: p-mitrale
CXR: LAE/ CHF signs
Echo: Fish mouth/ Left atrial thrombus
Definition
MS
Term
Normal v. Severe MS
Mean gradient
valve area
PA systolic pressure
Definition
Normal: Severe:
0 >10
4-6 <1
<30 >50
Term
Diagnostic testing of MS:
Imaging of choice and Use/Frequency
Definition
1. Echocardiogram
2. Assessment of severity based on MVA, mean gradient, PA pressure; Known MS re-evaluation with changing S/s; evaluate progression of ASX, stable patients via serial images
3. MVA:
>1.5cm = 3-5yr
1-1.5cm = 1-2yr
<1cm = annually
Term
Use of TEE in MS
Definition
presence/absence of LA thrombus; pre-op for percutaneous mitral balloon valvotomy
Term
Management basics of MS if pulmonary artery pressure >50mmHg
Definition
Class I -- consider PMBV
Term
Management basics of MS if pulmonary artery pressure <50mmHg
Definition
Exercise Stress Test
Term
Poor exercise tolerance / PASP >60 mmHg / PA wedge pressure =>25mmHg
Definition
PMBV procedure
Term
New onset AF with MS
Definition
Consider PMBV procedure
Term
What to do next:
Class II
MVA >1.5cm
Exercise stress test PASP > 60mmHg, PAWP =>25mmHg, MVG >15mmHg and class IIb MS
Definition
PMBV procedure
Term
What to do next:
Class II
MVA=<1.5cm
not favorable of PMBV
Sere PH; PAP >60-80mmHg
Definition
Commissurotomy/ MVR (replacement)
Term
What to do next:
Class III/IV
MVA =< 1.5cm
not favorable of PMBV
and not a high risk SX pt
Definition
MVR / Mitral valve repair
Term
What to do next:
Class III/ IV
MVA =< 1.5cm
not a high risk SX pt
Definition
PMBV procedure
Term
When is pharmacologic Tx appropriate for MS
What Rx are used for MS
What is the use of these individual Rx
Definition
Stabilization prior to intervention
1.Tx decompensation due to intercurrent illness
Post intervention Sx
2. Dignoxin-3. help slow ventricular rate/improve diastolic LV filling (not DOC)
BB/CCB (verapamil/diltiazam)- slow heart rate down- prevent angina
Limit exercise - decrease oxygen demand to prevent angina
Statins: slow progression of Rheumatic MS
Term
Preferred SX Tx of MS (definitive)
Definition
Valvotomy/Valve replacement (PMBV)
Term
Causes of MR:
Definition
Primary -MVP- degenerative MR
Secondary - Ischemic heart dz- CAD/major MR etiology
Term
Epidemiology of MR:
Transient MR think:
Definition
1. Female>male; Posterior leaflet MC
2. transient ischemia/papillary muscle involvement
Term
Acute v. Chronic MR
Definition
Acute- normal LA size/compliance, high LA pressure, low CO, high pulmonary venous pressure, pulmonary congestion, body compensates - venous constriction/ increase HR- increase MR problems
Chronic- increased LA size/compliance, more normal LA and pulmonary venous pressure, LV hypertrophies and dilates, stretches MR annulus, MR worsens low CO, HF
Term
Severity of MR is based on 5 things:
1 question from here
Definition
1. size of the regurgitation opening
2. Systolic gradient b/t the LA and LV
3. Afterload
4. LA compliance
5. Regurg durationq
Term
Loud, holosystolic, at paex and radiates to the axilla, best heart at the apex/LLSB, intensifies with hand grip
Definition
MR
Term
EKG - LAE, LVH
CXR: LAE/LVH
Echo: LAE/LVH
Definition
MR
Term
Functions of the pericardium
Definition
Limits the motion to within the mediasteinum, restricts sudden dilation of the heart, barrier to prevent infection from the lungs, Generally ASX if absent
Term
3 major dz of the pericardium
Definition
Acute pericarditis, effusion/tamponade, constrictive pericarditis
Term
Pt with: pleuritic CP increased with cough/position, distinctive EKG changes- diffuse ST elevation, pericardial friction rub on ausculatation
MCC Infectious
MCC Non-Infectious
Definition
Acute Pericarditis- acute inflammation of the pericardium
2. Idiopathic/vira (coxsackie A/B, CMV,
HSV, HIV)
3. transmural MI- inflammation extending from the epicardial surface to the pericardium-Dressler's Syndrome
Another cause- Neoplasm- Hodgkins Lymphoma, breast/lung CA can mestatsize to the heart leading to tamponade
Term
Pathophysiology of pericardium
Highest mortality is from what type of pericarditis?
Definition
cause, local vasodilation, increased vascular permeability, infiltration of pericardium with leukocyte exudation- inflammation, fibrin deposition, inflammation, rub and pain rom decreased space
2. Purulent pericarditis
Term
Variations correlate to likely etiology:
PMN, histocytes, thin exudate
MC yellow exudate, rough/shaggy, scarring of pericardiium- restriction of diastolic filling- cause, pathophysiology
Intense inflammatory response-cause, pathophysioloy
Grossly Bloody, serosanguinous-cause, pathophysiology
Definition
1. Serous
2. Serofibrinous (Bread and Butter)- direct cellular damage by virus, viral infected cell damage by sensitized T cells, ADCC
3. Suppurative- toxin and enzyme production by bacteria, myocardial damage, rapid tamponade onset
4. Hemorrhagic (TB/cancer)
Term
Pt with: Anterior CP, fairly sudden, provoked by inspiration/coughing, made better by sitting up/leaning forward, sharp pain that radiates to the shoulders/ neck (trapezius ridge); PE: pericardial rub, scratchy/squeak sound BEST HEARD with diaphragm over LSB
Definition
Pericarditis
Term
High risk acute pericarditis requiring immediate hospitalization?
Definition
Fever >100.4 and leukocytosis, large pericardial effusion, evidence of tamponade, immunocompromised, Hx of warfarin use, acute trauma, failure to improve with 7 days of NSAID Tx, elevated cardiac cTn-->myopericarditis
Term
Obtained in all cases of Pericarditis and findings
Definition
EKG -Concave up; diffuse ST elevation
CXR - Water bottle heart; pulmonary infiltrates
Echo - fluid in pericardial sac
Term
Labs should be drawn for pt with pericarditis (CBC/ESR/CRP/cTn) what other labs should be drawn in:
fever >100.4
TB screen is outdated
Permiscuous behavior
RA suspected
Definition
BC
PPD
HIV
ANA/RF
Term
most helpful in immunocompromised or (+) HIV AND in regions endemic with this dz?
Why not routinely obtain viral studies in a pt with pericarditis?
Test performed in pt used for Dx of malignant/ bacterial etiology/ refractory to medical Tx of pericarditis?
Definition
PPD
low yield/management not changed by results
Pericardiocentesis
Term
Tx for viral/idiopathic pericarditis
Definition
Rest
Rx: colchicine (3 mo) + NSAID(2wk) (unless CI (ie. MI/PUD)- ASA)
Steroids: ONLY is refractory to NSAID/colchicine/ASA
Term
Rx Tx: Dose/Duration/Tapering
Ibeprofen
Indomethocin
Colchicine
ASA
Prednisone
Definition
1. 600-800mg TID/ 1-2wk/ decrease weekly
2. 50mg TID/ 1-2wk/ decrease weekly
3. 0.5-0.6mg BID/ 3mo/ not done
4.650-1000mg TID/ 1-2wk/decrease weekly
5. 0.25-0.5mg daily/ 3mo/ 21 day
Term
definition of pericardial effusion
Definition
fluid in pericardial space exceeds the physiologic heart expansion capability leading to decreased EDV-->decreased CO-->tachycardia
(>250mL)
Term
Pericadial effusion/Tamponade severity is dependent on...
Definition
Volume of effusion
Rate of development (acute/chronic; no compensation/compensation)
Compliance characteristics of the pericardium
Term
Transudative etiologies of pericarditis
Exudative etiologies of pericarditis
Definition
CHF/hypoalbuniemia/hypoprotienemia/hypothyroidism
Trauma/post MI free wall rupture/AD
Term
pt with: dyspnea, dysphagia, hoarsness, hiccups, JVP increased with dominant "X" descent, decreased pulse pressure, rub, atypical CP(dull/ache/constant left sided CP)
Definition
Effusion Sx
Term
Pt with: JVD, hypotension, muffled heart sounds, atypical CP, "small quiet heart", tachycardia, loss of "y" descent on JVP, Pulsus paradoxus
Definition
Tamponade Sx
Term
Condition caused by SBP >10mmHg decrease during inspiration
Definition
Pulsus paradoxus
Term
Pericadial effusion/tamponade:
ECG
Definition
Effusion: Flat T waves, low voltage
Tamponade: Electrical alternans- pathognomonic, low voltage
Term
Pt with: CP, friction rub, fever, diffuse ST segment elevation + :
Inflammatory signs:
Large effusion with NO inflammatory signs/tamponade
Tamponade WITHOUT inflammatory signs
Definition
1. acute idiopathic pericarditis
2. chronic idiopathic pericardial effusion
3. Malignant effusion
Term
Further tests for
pericardial effusion:
tamponade:
Definition
1. pericardiocentesis
2. pericardiocentesis + cardiac cath
Dx and Tx; measure intracardiac/intrapericardial pressure
Term
Additional lab tests for exudates to narrow DDx:
Definition
Gram stain, C & S, neoplastic workup
Term
Effusion etiology of pericardial effusion
Definition
Malignacy/infectious/parainfections/ postpericardiotomy syndrome/ collagen vascular dz
high S.G., protien, Protien & LDH ratio, low glucose
(transudates is everything else; opposite lab values)
Term
Tx for:
Pericardial Effusion
Pericardial Tamponade
Definition
1 & 2- Tx underlying cause
1. Mild (ASX)-observe, serial echo
Mod-severe (Sx):Pericardiocentesis/catheter drainage/pericardiectomy- last resort
2. Aggressive fluid management, Pericariotomy (pericadial window)- recurrent
Term
Pt presents with: RHF, insidous onset, fimpairment of diasolic filling without impairment of systolic filling, abnormalities ONLY during diastole
Definition
Constrictive pericarditis
increase in RV pressure->increase fluid into PA->decrease in LV pressure->decrease CO->backs up into pulmonary tree->pulmonary edema
Term
Pt with: cachexia, precordial knock, RHF Sx, increased JVP (Kussmaul's Sign)
What is it?
Imaging of Choice?
What can r/o this dz?
Test that confirms this dz?
Definition
1. Constrictive pericarditis;
2. TTE; precordial knock(early diastolic heart sound before S3)
3. CT scan; additional info for pre-op
4. Cathe- distinguish b/t constrictive pericarditis v. restrictive cardiomyopathy
Term
Tx for Constrictive pericarditis
Definition
Pericardectomy
Term
Regurgitant volume/ orifice area in:
Mild:
Moderate:
Severe
Definition
1. <30 mL/beat; <0.2cm
2. 30-59mL/beat; 0.2-0.39cm
3. >=60mL/beat; >=0.40cm
Term
Use of TTE in MR is for?
Definition
baseline evaluation
annual/semiannual surveillance
function after a change in S/s
Term
Exercise Doppler echo use in MR?
Definition
1.reasonable to assess exercise tolerand and the affects of exercise on pulmonary after pressure
2.MR severity
Term
How to manage CHF in MR?
Definition
Acute setting: decrease the preload(diuretics/ vasodilators)
Chronic: no benefit from Rx; SX repair before deterioration occurs
Term
What SX is performed in MR?
Definition
1. MV repair(preferred)- optimal,mortality lower than for...
2. MV replacement
Term
MCC of organic regurgitation in US
Associated with these types of d/o?
Definition
MVP
Connective tissue d/o:
Marfans's/Ehlers-Danlos Syndrome/ OI
Term
MC Sx is ASX or non-anginal CP
Definition
MVP
Term
Mid systolic click, late systole murmur, increased by squatting, decreased by standing
Definition
MVP
Term
Imaging of choice for MVP?
When to use / not use?
Definition
1. Echo (TEE?);
2. Use:risk stratification in ASX patients w/ physical signs or Dx MVP
Not Use: exclude MVP in ASX pt, Routine repition ASX w/ MVP and w/wo MR and S/s
Term
MC congenital d/o in newborns
Definition
VSD
Term
When does the heart begin to form in fetal development?
Definition
3rd week
Term
L - R problems are typically caused by which type?
def of cyanosis?
Definition
1. Acyanotic lesions
2. Blue-purple discoloration of skin/mucous membranes--> increase de02 Hgb--> >=4g/dL-->80-85% SPO2
Term
Development of pulmonary vascular dz due to chronic large L-R heart shunt-->R-L shunt increasing the amount of deoxygenated blood to the system-->cyanosis
Definition
Eisenmenger Syndrome
Term
Fixed Split
Machine like murmur
Not a true ASD
Definition
ASD
PDA
PFO
Term
An ASD:
allows what?
Pathway of this?
Definition
Communication of the atria-->LA-RA-->oxygenated blood is sent back to the lungs-->less blood to LV-->decreased CO
Term
When does ASD develop?
What three structures are involved in ASD?
MC type of ASD?
Definition
1. 5th week of gestation
2. septum primum/septum secundum/ AV canal septum
3. Ostium Secundum
Term
Infants with a large ASD have what concomittant d/o?
Definition
HF/recurrent respiratory infections/ FTT
Term
ASD related questions:
Why no Sx until age 30?
Why fatigue and DOE?
Why fixed split of S2?
Why palpitations?
Why increased atrial arrhythmia?
Definition
1. not enough HR
2. Blood backed up into the lungs--> pressure results in fluid build up
3. Can hear seperate valves close b/c of pressure differential
4.Atrial enlargement leads to atrial tachycardia
5. Irritation of tissues + tachycardia --> arrhythmias
Term
ASD MC found where?
Definition
LUSB
Term
ASD:
Imaging of choice?
Management:
<6mm?
>8mm?
CI?
Definition
1.Echo
2. Spontaneous closure MC by age 2-5 y/o
3. Spontaneous is unlikely; SX is needed involving:
Large = Cardiopulmonary bypass-->pericardial/ Dacron patch
Small = suturing
4. Scuba diving
Term
Paradoxical Embolism
Definition
PFO
Term
MC CHD defect in infants and children?
Resolution of defect occurs by what age?
MC subtype of this defect?
Definition
1. VSD
2. 2y/o
3. Membranous VSD
Term
ASX, palpable thrill (4/6) along LSB, low pitched harsh holosystolic, best heard at the L mid- lower sternal border
Tx?
Definition
Small VSD
2. Followed by cardiology, echo, most close spontaneously
Term
Pt with: signs of HF at 3-4 w.o., tachypnea, FTT, hepatomegaly, grunting, retractions, RV heave, prominant and displaced apical impulse, reversal of shunt and a new diastolic murmur progresses
Tx?
Definition
Moderate-large VSD
2. Tx HF: Diuretics/ACE-I/Digoxin
FTT: Dietary interventions
SX
Term
Any VSD repaired posthetically w/wo residual effects should have prophylaxis for what procedures?
Time frame?
Definition
1. Dental/respiratory procedures
2. Repaired= first 6 mo
repaired w/ residual = lifetime
Term
PDA:
MC found in...
Why is the incidence rate increaseing?
What is the pressure in the Aorta?
Definition
1. Premature births/ 1st trimester maternal rubella infections
2. Increased survival rate of premature infants
3. Sys: 140-100, Dys: 90-60
Term
What usually happens with the Ductus arteriosus during birth?
Definition
Exposure to O2 causes contriction of tissue and gradual closure
Term
Pt with: Eisenmenger's Syndrome, Lower extremity cyanosis, UE remain acyanotic
Definition
PDA
Term
Pt with: Continuous machine-like murmur, best heard over the infra-clavicular area
Complications:
ECG/CXR changes:
Steps taken after Tx:
Definition
1. PDA
2. IE/ HF/ Pulmonary HTN
3. LAE/LVH
4. Prophylactic ABX for 6mo post PDA closure
Term
4 things that make up ToF?
Definition
VSD; Overriding Aorta; RVH; PA stenosis
Term
MC cyanotic heart defect requiring intervention during the first year of life?
Definition
ToF
Term
Pt with: DOE (why?), cyanosis, hyperventilation, squat after exercise/ when Sx are present (how does this help?), FTT, erythrocytosis, clubbing
Definition
1. ToF- tet spells 2. sending deoxygentated through system-->decreased O2 for cell use-->signals sent to medullary rhymicity center to increase respirations( doesn't make sense?) 3. kinks the femoral arteries-->increases systemic pressure-->decreased R-L shunt-->more blood flow into the lungs
Term
CXR: Boot shaped heart?
what is the definitive Dx of this d/o?
Tx?
Definition
ToF
2. Echo-->RVOFT
3. O2/genupectoral position/Bolus-->fails-->Morphine--> fails--> Propranolol/esmolol-->fails-->emergent SX
Term
MCC of death following SX repair of ToF?
Post op care of ToF?
Definition
1. arrhythmia/ HF
2. Prophylactic ABX for IE
Term
"Blue Baby", severity is dependent on concomittent ASD/VSD
Dx?
Tx?
Definition
Transposition of Great Vessals
2. Echo confirms
3. Emergent SX, PGE, balloon septoplasty
Term
Egg on a String shaped heart?
Definition
Transposition of Great Vessals
Term
Reversal of shunt leads to hypoxemia--> reduced Hgb--> increased RBC production-->Erythrocytosis-->Hyperviscosity--> HA/Fatigue/Stroke
Definition
Eisenmenger Syndrome
Term
Situations that increase the risk of Eisenmenger Syndrome?
Definition
Pregnancy, volume depletion, isometric exercise, high altitude, endocardial pacing, air emboli, SX
Term
MCC of Ebstein's Anomaly?
Definition
1st trimester Li use
Term
1st trimester bipolar mothers should be switched to a second line Manic/depressive controlling agent. Why?
Definition
Li can result in Ebstein's anomaly
Term
Endocarditis prophylaxis should-
used in:
NOT be used in:
Definition
1. Cyanotic patiens, prosthetic cardiac valves/repair,
2. Acyanotic pt w/ Ebstien's anomaly w/o Hx of valve replacement/endocarditis
Term
2 ways of classifying Duke's Citeria
Definition
1. Definite
2. Possible
Term
Bugs that cause IE?
Native
IVDU
Prosthetic valve-recent SX <1yr
Prosthetic valve-Remote SX >1yr
Definition
1. Strep/ S. Aureus
2. Strep/ S. aureus
3. S. epidermidis/ S aureus/ Enterococcous
4. Strep/ S. epidermidis/ S. aureus/ Enterococcus
Term
Average age of onset and valve MC affected:
Community acquired
IVDU
Definition
1. 60y/o; MV
2. 30y/o; TV
Term
RF for IE:
Definition
>60y/o
Male
Structural Heart Dz
Prosthetic HeartValve
Congenital Heart Dz
Indwelling catheter/ Intravascular procedure
IVDU
Hx of IE
Poor dentition/ Dental infection
HIV
Term
Pathophysiology of IE:
Definition
endocardial surface injury-->thrombus formation-->bacteremia attach-->multiply-->stimulates further thrombus formation and creation of vegetation-->local destruction/immune injury-->hematogenous seeding-->emoblization(septic)
Term
#1 S/s of pt with IE
Definition
Fever
Term
Minimum citeria needed for:
Definite IE
Possible IE
Definition
1.Pathologic Criteria:
Microorganisms found in: culture/tissue/seeding of embolus/intracardiac abcess
Pathologic: vegetation/intracardiac abcess based on histology
Clinical Criteria:
2 major/1 major + 3 minor/ 5 minor
2. 1 major + 1 minor/ 3 minor
Term
Major Criteria:
Definition
1. (+) BC:
2 seperate blood cultures
Persistantly (+) = (+)BC 12h apart OR All of 3 or a majority of >=4 with the 1st and last drawn >1h apart
Single (+) BC for Coxiella / Antiphase 1 IgG AB titer >1:800
2. Evidence of endocardial involvement:
(+) echo for IE-->TEE for prosthetic heart valves/ TTE for everyone else
New valvular regurgitation- increase in/change in pre-existing does not count
Term
Minor Criteria:
Definition
Predisposing factors-Heart condition/IVDU
Fever
Vascular phenomena
Immunologic phenomena
Microbiologic evidence
Echo
Term
Minor Criteria-->definition:
Predisposing factors
Fever
Vascular phenomena
Immunologic phenomena
Microbiologic evidence
Echo
Definition
1. heart conditions/ IVDU
2. >100.4
3. major arterial emboli/ septic pulomnary infarcts/ mycotic aneurysm/ intracranial hemorrhage/ conjunctival hemorrhages/ Janeway lesions
4. GN/Osler's nodes/ Roth Spots/ RA factor
5. (+) BC- not meeting major criterion
OR
Serologic evidence of IE organisms
Term
major criteria:
When should BC be taken
Echocardiogram background
Definition
1.before ABX
minimum of 3 from different sites
2. NEW regurgitation
TTE- initial test of choice- detects large vegetations, quantifies valvular dysfunction, non-invasive easy
TEE- More sensitive, useful evaluation for prosthetic valves
Term
Over what time frame should BC be obtained in acutely ill pt
Definition
over 1h time span
Term
IE Dx:
Labs taken and results
Definition
BC- microorganisms
Urnialysis- Proteinuria
CBC- Normocytic, nomochromic anemia, elevated WBC-->mostly PMN
Acute phase reactants- CRP/ESR elevated
(+) RF
Term
Initial Tx decisions of IE:
Definition
empiric ABX Tx OR ABX based on C&S
Term
How to Tx IE pt:
stable pt, not acutely ill:
unstable acutely ill strong suspicion of IE:
Definition
1. admit, wait on BC results (1-3d)--> accurate Dx is key
2. admit-->emipiric ABX Tx (vancomycin) after BC collection (drawn: 2+ sites, 20-30 min b/t)
Term
IE Tx with BC results of:
Strep
Staph oxacillin susceptible
Staph oxacillin resistant
Staph oxacillin resistant PCN allergy
PCN allergy
Fungi, Brucella spp, P. aeruginosa
Definition
1. PCN G
2. IV nafcillin + gentamicin
IV Cefazolin + gentamicin
3. Vancomycin
4. Ceftriaxone / Ceftriaxone+gentamicin
Vancomycin
5. cephalexin/macrolides/clindamycin
6. SX
Term
After ABX initiation when do pt become:
afebrile
better
done with Tx
Definition
1. 7 days
2. 2wks
3. 4-6wks
Term
Highest risk pt requiring IE prophylaxis:
Definition
Prosthetic cardiac valve
Previous IE
Congenital heart dz
cardiac transplantation->valvulopathy
Term
Which phase and definition of:
Plateau phase
Repolarization
Definition
1. phase 2; prolonged cardiac action potential-->sustained/increased contraction
2. Phase 3; Ca++ channels close-->continuous K efflux-->neuron mV drops
Term
Which cells have less "coupled" intercalated discs?
Definition
Pacemaker cells (SA node especially) as compared to non-pacemaker cells
Term
Arrhythmias classification:
2 types of classes and Arrhythmias found in that class
Definition
1. Altered impulse formation-->
Altered normal automaticity (SNS/PNS)
Abnormal automacticity-> secondary pacemakers taking over (AV node, etc.)
Triggered activity->often by drugs
2. Altered Impulse Conduction->
HB/ transient (MI/electrolyte imbalance) v. permanent/ unidirection v. bidirectional/ AVRT/ AVNRT- Bundle of Kent- WPW; James bypass tract- LGL/
Term
Arrhythmias:
Cause of early depolarization?
Rx condition commonly causing a delay after depolarization?
Definition
1. Torsades
2. Dig toxicity
Term
Pt: ABC's are taken care of, monitor shows a tachycardia rhythm, pulse is felt, hypotensive and shows signs of shock. Next step?
Definition
Synchronized cardioversion- narrow complex consider adenosine (6/12/12)
Term
Pt: ABC's are taken care of, monitor shows tachycardia showing >0.12 QRS complexes, pulse is felt. Next step?
Definition
IV access
12 lead EKG
Adenosine (6/12/12)- monomorphic
MgSO4
Antiarrhythmics
Expert consultation
Term
Antiarrhythmics: name
Bradycardia Rx: name
Cardiac arrest Rx: name
Definition
1. Procainamide
Amiodarone
Sotalol- not for prolonged QT
2. Atropine, Dopamine, Epinepherine
3. Epinepherine/ vasopressin/ amiodarone
Term
Pt: ABC's are taken care of, monitor shows a tachycardia rhythm, pulse is felt, stable, not widened. Next step?
Definition
IV access
12 lead EKG
Adenosine - if regular
B-blockers/CCB
Expert consultation
Term
Pt: ABC's are taken care of 12 lead is establihed and shows bradycardia, pulse is felt, AMS with ischemic chest discomfort. Next Step?
Definition
Atropine-->Pace/Dopamine infusion/Epinepherine-->expert consultation
Term
Pt: ABC's are taken care of, monitor shows bradycardia with a palpable pulse, stable. Next Step?
Definition
Monitor and observe
Term
Pt: ABC's established, monitor shows VT, no pulse felt. Next step?
Definition
Clear!!
CPR - IV access
Rhythm Check
Shock again
CPR- epinepherine, advanced airway placement
Rhythm Check
Shock
CPR- Amiodarone (300/150)/ consider H/T's
Repeat
Term
Coexising d/o influencing heart rhythm/rate:
Cardiac d/o related
Non-cardiac d/o related
Labs to order:
Studies to order if arrhythmia is: very infrequent but concerning
Frequent- 1d study
Frequent- <4wk study
Definition
1. CAD/CHF/Cardiac Risk Factors
2. Hyper/hypothyroidism/Anemia/COPD/Chronic hypoxia
3. CBC/TSH/Electrolytes (Ca/Mg)
4. Implantable loop recorder
Holter monitor
Event monitor
Term
Tilt Table testing:
Indications
CI
Definition
1. Syncope; no structural causes w/ everything else r/o
2. Syncope with known structural cause
Term
Most frequent cause of compensatory pause
Tx for SVT:
Sx and ASX
Definition
1.PAC
2. Sx-> avoid triggers(EtOH/B blocker/Catheter ablation->Sx/APB->AF
Term
Typically occurs in pt with pre-existing heart dz
Definition
Atrial Flutter
Can occur after initiation antiarrhythmis drug supressing-->flecainide
Term
Atrial flutter has an increased likelyhood of?
Definition
Thromboembolic events->stroke/DVT
Term
Atrial flutter->management
Rate control:
Rhythm control/conversion:
Stable:
Definition
1. Atrial flutter rate is difficult to control (most stay 2:1)->non-DHP CCB/BB/Dig
2. Synchronized cardioversion-> unstable/stable->cardioversion: ibutilide-DOC
3. Anti-coagulation-> CHA2DS2VASC:
CHF, HTN, Age(>75), DM, Stroke 2 Vascular dz, Age 65-74, Sex category
Term
Etiologies of Atrial fibrillation:
Definition
PIRATES:
Pulmonary embolism
Iatrogenic(cardiac SX)
Rheumatic heart dz (MR/MS)
Acute coronary syndrome/Coronary heart dz
Thyroid (hyperthyroidsm)
EtOH- holiday heart
Sleep-> OSA/Sick heart HF
Term
MC arrhythmia requiring Tx
Definition
Supraventricular
Term
1. Self-terminating/intermittent; <7d
2. AF fails to self-terminate <7d;pharmacologic/elecrical cardioversion
3. AF lasting >12mo
4. Persistant AF and a joint decision by the patient AND clinician to d/c further rhythm control strategy
Definition
1. Paroxysmal AF
2. Persistent AF
3. Long-standing persisent AF
4. Permanent AF
Term
No "a" waves on JVP
Definition
"a" waves are the atrial kick, no atrial kick, no S4 heart sound
Term
A flutter v. A fib
Definition
A fib= no P waves, irregularly irregular
Term
A fib-> HOTN/ischemia/ severe HF/cerebrovascular-> what to do next?
A fib-> H&P/ Dx (ECG/TTE/TEE)-> what to do next?
Definition
1. Cardioversion
2. Determine underlying etiology and Tx
Term
A fib->preferred control approach for:
Younger pt
Older pt
Definition
1. <60; rhythm control->cardioversion + antiarrythmics
2. >60; rate control->Rx->slow AV node
Term
A fib->management-> who is at risk for thrombotic formation?
Definition
1. New onset AF- related to rapids ventricular response
2.Extremely high risk->A fib w/ valvular heart dz
Term
AF <48h duration w/ HF/DM/CHA2DS2VASC score >=2-> Tx
Definition
Heparin/LMWH/Dabigatran/Apixaban ASAP prior to cardioversion
Term
AF >48h/unknown duration->management:
Definition
1. Min. of 3wk->Warfarin(DOC) w/ INR 2-3->prior to cardioversion
2. TEE->after target INR/2d of dabigatran/apixaban
Term
Post-cardioversion Tx
Definition
1mo PO of warfarin/NOAC
Term
A fib->management->rate control->Pharmacologic Tx with what Rx
Definition
BB/non-DHP CCB/Dig(HF related)->use in AF and Preexcitation syndrome WPW->CAUTION-->AV nodal blockers->paradoxical ventricular response-> prevent->Urgent, stable=IV procainamide/Ibutilide OR Unstable=DC cardioversion
Term
A fib->management->rate control->electrically?
Definition
Anti-coagulation Tx prior to cardioversion
If unstable->IV heperin(do not delay cardioversion)
Term
A fib->managment->rhythm control for symptomatic paraoxysmal AF->TOC, alternative if TOC is CI/failed
Definition
1. AAD= flecainide/amiodarone/sotalol/dronedarone
2. catheter ablation recommended for:
Sympotmatic paroxysmal AF->young pt/AAD complications/ failed AAD
Symptomatic persistent/longstanding persistent AF->AAD CI/failed
Term
How does amiodarone work?
Definition
Blocks K channel blockade->slows repolarization->prolongs AP and refractiveness of myocardium
Term
Advantages and disadvantages of Direct thrombin and factor Xa inhibitors?
Definition
Adv: no IRN monitoring/less diet or drug interactions
Dis: BID/ $$$/ no reversal
Term
Problem with Warfarin?
Risk of INR at:
<1.8
>3.5
Definition
1.Narrow therapeutic range/food interactions (spinich)
2. doubles stroke risk
3. increases risk of bleeding
Term
Refractory AF->management:
Definition
Tx directed towards ostial portion of Pulmonary veins->MC site
EP intervention
RFA-radiofrequency ablation->circumfrential/focal
MAZE procedure
Obliteration of L atrial appendage
Term
PSVT? 3 types->MC type
MCC of narrow QRS complex tachycardia?
Definition
AVNRT (MC)/AVRT/ Atrial tachycardia
Re-entry
Term
MAT v. WAP
MCC of MAT
Definition
same thing, but MAT >100bpm v. WAP <100bpm
intermittent episodes of PSVT->Lung dz->usually permanent arrhythmia (p-MAT)
Term
WPW:
Type A
v.
Type B
Definition
1. Antidromic; more dangerous->AV node cannot slow conduction
2. Orhodromic: less dangerous b/c still has to pass through AV node normally and can be contolled/paused slightly
Term
PSVT->management-> AVNRT->basis of Tx
Definition
Stable v. Unstable->ACLS algorhythm
Rate v. Rhythm control-> decison based on:
Frequency/Sx severity/Rx tolerance/pt preference
Term
PSVT->Managment->AVRT->Antidromic/Orthodromic
Which rhythms to cardiovert?
Definition
1.antidromic: IV procainamide
Orthodromic: vagal, IV adenosine, IV verapamil
2. WPW and unstable rhythm
Term
PSVT->managment:
WPW
AT(FAT/MAT)
Definition
1. catheter ablation
2. Rx->rate control-> BB(unless CI=CCB)
Ablation->Rx CI/failure
Term
SVT
v.
VT
Definition
1. Narrow; slowing/termination with vagal
2. wide; AV dissociation/other non1:1 AV relationship; Fusion beats, capture beats
Term
PVC:
Worst outcome with which patients?
With exercise?
Definition
1. Post MI patients
2. if they stop with exercise cessation=benign
Term
Sustained VT
v.
Nonsustained VT
Definition
1. BAD, underlying structural dz, >30s
2. series of at least 3 consecutive ventricular beats->duration of <30s/do not require emergency intervention
Term
How to distinguish Ashman's Phenomenon from PVC's?
If unable to distinguish SVT v. VT what to do?
Definition
1. Fixed R-R with Ashman's phenomenon
2. Tx as VT
Term
VT->management:
ASX and non sustained
Acute sustained->monomorphic v. polymorphic
Acute sustained-> Stable
Acute sustained->unstable
Definition
1.Tx underlying cause
2. Have structural heart dz determines Tx
3. ACLS->cardiovert(pulse)/DFIB(pulseless/TdP)
4. cardioversion->procainamide/amiodarone/IV mag sulfate(TdP)
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